If you are an existing patient needing help, we have a few options for you.
1. Use our patient portal.
2. OR – Call us at 630-371-9980
3. OR – If you are having any difficulty with the phone system, please email at PatientHelp@painchicago.com
4. OR – fill out the following form:
Please complete pain diagram and bring to your appointment. If there are any Demographic/Insurance changes or HIPAA updates, please complete and bring to your appointment. Thank you.
Forms:
- Patient Demographics
- Signature Sheet
- HIPAA Form
- ARI Form
- Requisition for Forms – FMLA and Other
- Authorization for Release of Medical Records
(Please complete a request for form and fax it to our office at 630-371-1555. There is a 10 business day turnaround time) - New Patient Packet
- Request Medical Records
- Benefits Assignment Policy
- Interventional Procedure Instructions
- Credit Card Authorization Form
- Patient Agreement for Controlled Substances
- Release of Medical Records Form
Policies:
- Notice of Privacy Practices
- Opioid Policy
- Controlled Substance Agreement
- Opioid Consent for Treatment
- Controlled Substance Policy

I have known Dr. Scott Glaser for over 20 years. As a physician practicing geriatric medicine, I referred many of my patients to Dr. Glaser to address their various pain issues. My patients were always pleased with their outcomes and with Dr. Glaser's genuine concern to help in any way he could. Now, as a patient of Dr. Glaser myself, I have recently undergone treatment for my chronic back pain with radiofrequency ablation. After living with the pain for several years it is so amazing to be virtually pain free after my procedure. Dr. Glaser assessed my situation and knew exactly the best way to treat me. I cannot thank him and his entire staff enough for truly remarkable care. Now I fully understand why my patients were so happy with my referrals to Dr. Glaser.
I have had lower back pain for years. Periodic steroid injections usually helped but the relief was not permanent. Dr. Glaser advised me of a new procedure called "Intracept Procedure". In March of 2025 Dr. Glaser performed the Intracept procedure on me. He said the full benefit of the procedure might take several months. On a recent visit to Dr. Glaser in July, I told him my lower back pain was gone. For someone who has chronic lower back pain, this procedure might be what you need.
Learn about our 72 Hour Commitment to your pain relief.
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